Endometriosis NEWS.Direct! by iLogy iLogy

Endometriosis NEWS.Direct!

December 2010-January 2011

INTERVIEW Minimally Invasive Surgery for Endometriosis Dr. Shylaja B. Rajiv, Assistant Editor, Endometriosis NEWS. Direct! interviews Dr. Tal about a clinician’s perspectives on surgical managment of endometriosis. Q: Laparoscopy is considered as the ‘gold standard’ for the definitive diagnosis of endometriosis. Is there a sense that there is an increase in the number of unnecessary diagnostic laparoscopies and do you think there is any scope for reducing the same without missing the diagnosis? A: In my own practice, I will often consider a trial of empirical treatment of suspected endometriosis without confirming the diagnosis by laparoscopy. If the patient is happy with this management and the possible uncertainty, then I consider it to be perfectly acceptable. For example, ‘The Pill’ for dysmenorrhea is fine if it works quickly and effectively, but persistent symptoms should be investigated further with a laparoscopy. Nevertheless, there has been a lowering of the threshold to perform laparoscopy since it is perceived to be increasingly safe and effective. In my experience, I do not think that unnecessary laparoscopies are increasing, but surgery should always be undertaken with a clear goal in mind and a justification for the procedure that can be sustained, regardless of the outcome. Not finding endometriosis can be just as important as finding it.

Dr. Tal Jacobson MA MRCOG FRANZCOG Sr. Lecturer, University of Queensland, Staff Specialist, Mater Mothers’ Hospital Department of Obs and Gyn, Aubigny Place, Raymond Terrace, South Brisbane, Australia

Q: Can you please explain briefly the basis of surgical management of the different stages of endometriosis? How often do you do bowel resection and what is the acceptance of such surgery in Australia and New Zealand? A: All surgery planning depends on the underlying concerns of the patient and may also vary depending on whether pain or fertility is the specific concern. The underlying basis of the surgical management of endometriosis is to remove disease and restore anatomy. Surgical management of Stage I and II disease is usually straightforward with the excision of peritoneal endometriosis and the removal of adhesions. Stage III and IV requires the same principles but with a greater focus on restoration of anatomy and full excision of deep endometriosis. According to the Cochrane systematic review evidence, endometriomas are best excised, rather than ablated. Full excision of stage I and II endometriosis is usually advocated, but there is significant evidence that ablation alone or incomplete excision provides very similar outcomes. I am reasonably conservative in my recommendations for bowel resection and will usually perform less than 20 per year. The operation is well accepted and has a good outcome, but requires extensive preoperative counseling to ensure that patients are aware of the alternatives, likely outcomes and potential complications, and allow them to make an informed decision about whether or not to proceed to surgery.